Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions with Connection to Primary Care Within 7 Days of Hospital Discharge

Dawn Wiest
Qiang Yang
Cater Wilson
Natasha Dravid
Journal Article
January 2019

This resource describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

  • Previous research suggests the important role of timely primary care follow-up in reducing hospital readmissions, although effectiveness varies by program design and patients’ readmission risk level.
  • In a retrospective cohort study of hospital readmissions among adult Medicaid patients in Camden, New Jersey, patients who attended a primary care follow-up appointment had fewer 30- and 90-day readmissions compared with patients with less timely primary care follow-up or none.
  • This Quality Improvement Brief elaborates on the quality improvement aspects of the work.
  • This Clinical Redesign Brief offers guidance on how to replicate this program in other communities.
Posted to The Playbook on
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • Is connection to primary care within seven days of hospital discharge associated with reduced readmissions?
  • What is the evidence?
Level of Evidence
What does this mean?